California's Uninsured on the Eve of ACA Open Enrollment

CA Uninsured Executive Summary

For the purposes of this report, the ‘eligible uninsured’ are California residents ages 19-64 who have been uninsured for at least two months, and would be eligible for participation in the ACA coverage expansion based on their self-reported status as a citizen, permanent resident, or lawfully present immigrant. See Section 5: “About the terms used in this report” for more details.

For the purposes of this report, ‘undocumented immigrants’ are defined as those who reported they were born outside the United States, came to the U.S. without a green card, and have not received a green card or become a permanent resident since arriving. See Section 5: “About the terms used in this report” for more details.

Introduction

For more on California, see “California’s Health Care Environment and Health Reform Efforts”, KFF, June 2013, http://kaiserfamilyfoundation.files.wordpress.com/2013/06/8454-california_s-health-care-environment.pdf.

Kaiser Family Foundation analysis of CMS data, downloaded at: https://data.cms.gov/dataset/The-Number-of-Estimated-Eligible-Uninsured-People-/pc88-ec56. Note that these numbers exclude those who are ineligible due to immigration status. These numbers likely overestimate the number of eligible adults in each category for two reasons: 1) Breakouts by poverty level include children, as it was not possible to break out data by poverty level and age; and 2) Some of those in the middle income range (greater than 138 percent and up to 400 percent FPL) may be ineligible for subsidies if they have access to affordable employer coverage, a condition that could not be determined from these data.

Section 1: California's uninsured and the ACA

Section 2: The uninsured experience, pre-ACA

Kaiser Health News, HHS Will Allow ‘Unbanked’ People To Use Prepaid Debit Cards On Exchanges, August 29, 2013, available at http://capsules.kaiserhealthnews.org/index.php/2013/08/hhs-will-allow-unbanked-people-to-use-prepaid-debit-cards-on-exchanges/

Section 3: California's undocumented uninsured

For more information on the current shape of immigration policy and the ACA, see KFF Issue Brief, Immigration Reform and Access to Health Coverage: Key Issues to Consider, available at http://www.kff.org/uninsured/issue-brief/immigration-reform-and-access-to-health-coverage-key-issues-to-consider/

CA Uninsured Survey Methodology

Those who had been uninsured for less than two months were excluded from the survey since they may be experiencing a short period of uninsurance (i.e. someone who is between jobs), and the goal of the survey was to capture the experiences and views of those who have been without insurance for a longer period of time and are poised to experience the new coverage provisions of the ACA.

With over half of California’s total uninsured population being of Hispanic descent, it is essential to include Spanish interviewing as an option when surveying this population. Due to the diversity of languages spoken by California’s Asian population, we were not able to translate the questionnaire and conduct interviews in the many various Asian languages spoken by some of California’s uninsured. Roughly one in ten uninsured Californians are of Asian descent, and according to the Census, about half of this group says they speak English less than “very well.” Further, survey participation among Asians as a whole tends to be lower than among whites. As a result, we did not obtain enough interviews with Asians to report their results separately when breaking out results by race/ethnicity. Responses for Asians are included in the total, and are weighted so that they represent the appropriate share of the uninsured population. The views of non-English-speaking Asians may be underrepresented in this report, but given the small share this represents of the overall uninsured population, it is not likely to have a material impact on the overall findings.

For purposes of income grouping and weighting, income (categorized as a percent of the federal poverty level) is aggregated by “health insurance units.” This unit includes members of a family who can be covered under one insurance policy: the policy holder, spouse, children under age 19 and some full-time students under age 23. Other family members (e.g., grandparents) who may be living in the same household might not be included based on program eligibility; therefore, their incomes are not part of the income used to calculate poverty levels. The health insurance unit more accurately reflects the income that would be counted when people apply to Medi-Cal or purchase health insurance through Covered California. The U.S. Census Bureau produces simplified - but very similar - versions of federal poverty guidelines called family poverty thresholds.

74 respondents declined to answer questions about family size and income, and so were not classified into one of the 3 income groupings, though their responses are included in the analysis of all eligible uninsured.